I hereby confirm that the information provided is true and correct and that I have the authority to do so.

We require a scanned copy of the representative's green barcoded ID book:

We require a scanned copy of a utility bill as proof of residence:

3. Bank Account Details

We need this information to assess your credit status:

Name of Bank:

Account Holder's Name:

Type of Account:

CurrentSavingsTransmission

Account Number:

Branch Code:

How many years have you banked there?:

4. Debit Order Authorisation

Would you like to pay your Checkers Business Card by debit order:

If yes, please complete the details below:

Name of Bank:

Bank Account Name:

Type of Account:

CurrentSavingsTransmission

Bank Account Number:

Branch Name:

Branch Code:

Authorisation:

I hereby confirm that the information provided is true and correct and that I have the authority to do so.

We require a scanned proof of banking details in the form of a cancelled cheque or certified copy of your current bank statement.

5. Preferences

Would you like to receive your communication in:

EnglishAfrikaansOther

If for some reason it is not possible to communicate with you in your preferred language, we will communicate with you in English

Would you like to receive your statement via:

PostE-mail

Would you like to receive important account information via SMS:

NoYes, please provide Cell Phone Number:

6. Purchase Limit

Purchase limit applied for:

R

7. Signature

I hereby confirm that all details supplied above are true and correct. I acknowledge that I have read and understand the Terms and Conditions attached to this application form and undertake on behalf of the Applicant to abide by the rules governing the Checkers Business Card. I warrant that I am duly authorised to make this application on behalf of the Applicant.